RACs and RUCs and 99204s, Oh My!!!

Today is the next installment in the New Patient Office Visit Series.

We will be covering the 99204 CPT code. In 2003 it was selected 30% of the time for the new patient encounter.....which means just about 65% of patients fit into the 99203 or 99204 zone. My guess is that by the time we are done, you will be using 99204 much more than not.

So what is a 99204?

99204 requires these 3 components

1. A "Comprehensive" History

2. A "Comprehensive" Examination

3. Medical Decision Making of "Moderate" Complexity

Once again the definition of Moderate and Comprehensive are key here.

Moderate Complexity Decision Making is often audited and requires:

A. Multiple Diagnoses or Management Options. AMA doesn't list the exact number here but E and M University has a good wrap up 

The take home is that new problems with additional work up gets a maximum of 4 problem points. If it is a new problem with no further work up it is 3 points.

You can feel pretty confident  billing 99204 here if you have 3 points here AND

B. Amount and/or complexity of data reviewed has to be moderate as well. 

In this case you would need 3 data points reviewed. Ordering clinical lab tests counts as 1 point. So does ordering a radiology test, the same with EKG.

Discussing the results with a physician gives you a measly one point as well. But independent review of the specimen, image or tracing gives you 2 points......

So if you looked at the film, document that you looked at the film....or EKG.....

Review and summation of Old Records ALSO gives you 2 points.......

You can consider yourself getting warm here if you have 3 data points here AND 3 problem points.......

C. Moderate Risk of Complications, Morbidity or Mortality.....Well, what does that mean?

You can turn to the "Table of Risk!"

This basically indicates that you have one thing of 3 categories......

Category A-Presenting Problems

One or more chronic illnesses with mild exacerbation

Two or more stable chronic illnesses (HTN and Hyperlipidemia)

One Undiagnosed New problem

Acute Illness with Systemic Symptoms

Category B-Diagnostic Procedures

Stress Test or Fetal Stress test

Diagnostic Endoscopies

Deep Needle or Incisional Biopsies

Cardiac Cath

Fluid removal from Body Cavity

Category C-Management Options Selected

Minor surgery

Elective Major Surgery

Prescribing Medicines

IV fluids

Closed treatment of a fracture

So, you need one of each category to qualify Risk as a moderate data point

Listen, this system is complicated here.....My gut tells me that you should not count on using Risk as 1 of your 2 required points to qualify MDM as moderate complexity.

My take home on MDM is-Always review your own data, Always review old records, 

Always document new problems and demonstrate your work up of them......If you do these things you will likely qualify for moderate MDM

Now that's over, let's look at a Comprehensive Exam

Comprehensive is defined as 

1. "A general multisystem examination"

2. " A complete examination of a single organ system"

Organ systems are:

Eyes

Each Extremity, I repeat EACH Extremity

Ear, Nose,Throat and Mouth

Eyes

CV

Respiratory

GI

GU

Musculoskeletal

Skin

Neurologic

Psychiatric

Heme/Lymph

If you set up a template of your exam as such, you will do well in documenting these events. The take home here is that to be complete you would need 2 bullets for each of the 9 systems.......Ah silly coders, they have to be so precise in defining complete.....do they really know what complete means?

I go over bullets and the exam in prior posts 

This is a gimmee here. Anyone would do this for a new patient......Anyone......Count Complete physical as one of the 2 Categories filled

Lastly,

Complete History. This bugger is considered the Highest Level of History. Which means often people try but fail at performing this.

This history includes:

1. Chief Complaint

2. "Extended" HPI

3. Review of systems related to the problems in the HPI PLUS all other systems

4. COMPLETE Family, Social and Past Medical and Past Surgical History

I will go through each in detail, but suffice to say.....you should be doing these things for ALL new patients if you want to code a 99204.....I actually do this for ALL of my new patients....I will explain why shortly...

The big question here is likely to be What is a COMPLETE PM/PS/Soc/FamHx (PFSHx)......One thing it isn't is NonContributory.......It is at a minimum-Parents, Siblings AND Children! I do grandparents too!

This includes Medicines and Allergies! I repeat, this includes medicines and allergies....

I plan on covering this in another post, but just keep these tips in mind.

Is the patient married? Are they employed? Have they had education? Do they have exposures? Sex? Drugs? Rock and Roll? 

Remember, nearly all outpatient codes require some elements of this here. So it is just good sense to do this at EVERY encounter.....

And most importantly, the PFSHx can be taken by another person, OR EVEN a Form......

What does this look like in real time? 

Initial visit for a 59 year old woman with HTN, Obesity, OA. She has a complaint of palpitations with some occasional dizziness. Her PMSFHx includes TAHBSO for DUB 15 years ago. She has not been seen for 5 years.

If this new patient is also here for a complete physical exam....there is something I need to share with you.....it is called Modifer 25....the name of this blog! 

Want to learn coding and billing? Want to put 5 billion back in your pockets? Join us....email us at modifier25@gmail.com

How a code becomes a check......

What I love about learning this whole system is that you begin to understand that people who are not doctors are always trying to quantify what you do and how you do it. Things such as RVUs turn a clinician into a blue collar worker. 

It is one of the most disgusting things that I have seen. That's why I gave up working for anyone who wishes to tell me how productive I am. At the end of the day, just ask my patients, they will tell you how productive I am......

This coding and auditing system cracks me up. Here you have a bunch of people from the AMA, HCFA, and other organizations trying to explain what we do in a very, VERY detailed way, without having the direct professional understanding of how we do it.

Granted, there are some physicians on these panels......but they are NOT all specialties or the majority. CPT was started in the late 60s and encouraged to use as a data reporting tool, to "standardize" what we do......sounds eerily familiar to PQRI.....

It was then accepted by Medicare in 1983 as the mode of reporting for reimbursement......that's when hell came on earth.......slowly...

The CPT manual is updated annually through an editorial review process. The CPT Editorial Panel meets 3-4 times per year to review requests received from specialty societies, manufacturers and individuals. The Panel is supported in its deliberations by a larger body of CPT advisors, known as the CPT Advisory Committee

This body, it is oft complained as existing to serve the specialists and not the generalists.....This could be seen as sour grapes, or it could represent a serious lack of voice....

Either way, you have a coding committee who may not represent all parties.....Which is not  an equitable or reasonable position to take.

That being said

Once a coding change is accepted by the CPT Editorial Panel, the next step in the CPT process is to determine the reimbursement for the code, through a survey of physician work and determination of direct practice expense (PE). The survey results are submitted to the RUC for negotiation for a mutually acceptable value to be submitted to CMS for final approval and publication in the Federal Register Final Rule. The approved CPT code and their associated RVUs are then published. 

You may be asking......What is the RUC and What is an RVU

The RUC is:

The Relative Value Update Committee, a decision-making body which reviews all surveys of physician work values (52 percent of the total RVU for a service/procedure) and practice expense or PE (44 percent of the total RVU for a service/procedure) and makes recommendations regarding these components to the Centers for Medicare and Medicaid Services (CMS) for reimbursement  determination. Members of the RUC are appointed by national medical specialty societies.

What in an RVU?

An evil way to turn us into worker bees, rather than professionals....

If you really must know, then you can read about it here.

Relative value units

Although several relative value systems are recognized and used nationally, the most identifiable system is the Resource-Based Relative Value Scale, or RBRVS. The RBRVS system was adopted in 1992 by CMS as a method for setting Medicare reimbursement levels. Under the RBRVS methodology, services are assigned a numerical value or weight, which is relative to all other codes. The numerical value, or relative value unit (RVU), is actually made up of three component units — designated for work, practice expenses, and malpractice expenses.

To set the Medicare allowable rate, the component units are factored by corresponding geographic indices, summed, and then multiplied by a standard conversion factor. Basically, it is a lot of economic shenanigans to devalue what we do....

 Each year, CMS makes changes to the RBRVS component units, based upon the introduction of new CPT codes, changes to code values by the American Medical Association (AMA) and specialty societies’ RUC (Relative Value Update Committees), and government budget constraints and indices.

For the last decade or so, Mediare has been trying to cut payments to physicians, despite practice expenses and malpractice expenses going up each year. Funny really when you think that their equation relies so heavily on these 2 factors. The real issue lies in the standard conversion factors......

With one simple change of an equation, the entire system, which is already on its knees, could be dropped to the floor.

So, the question becomes, "So this is Medicare and Medicaid, what about regular insurance?"

The AMA receives approximately $70 million annually from licensing fees for anyone wishing to relate RVUs with CPT codes, making them reluctant to allow the free distribution of tools and data that might help physicians calculate their fees accurately and fairly.

I.E. the AMA makes millions off of the insurers who want to use the governmental system for setting their fee schedules....

So, the AMA is in bed with the government AND the commercial insurers.....to "help the doctor-members"

But just like most politicians who go to Washington, this system is corrupted. And we need to fix it, by learning the system and using it to our advantage to get paid fairly for what we do.

That my friend is how we turn a code into a check.....I am going to post links to each of these important boards.

About the RUC only 5 of the 29 are primary care. 

Not exactly the 2/3rds majority required to change payments....Did you know that the AMA could have been threatened with Anti-Trust laws by telling the public what this committee does?

I can't find the membership of the CPT editorial committee.....does anyone have this information???

Want to join us? Want to share your opinions about coding and billing? Want to put that 5 billion back in your pockets????

Email us at modifier25@gmail.com and we'll set you up to post on this blog!

What's the difference in physical exam types? Bullets and 1997.

I actually have seen these in a few shrouded away places...But most physicians don't know these rules......You see, in 1997 the EM physical exam rules were updated from the loosey goosey rules of 1995.....They rely on these "Bullet Points" which allow atomatons to check the boxes and audit our charts much easier. It also allows for the automation and creation of EMR exam forms....i.e. "check the box" or "Check the Bullets"

Here are the 1997 Physical Exam Rules, Couched with levels of physical examination.

1997 Physical Exam Rules General Multi-System Exam 1997 Problem Focused Exam One to five bullets from one or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Lungs: CTA  CV: RRR, no MRGs  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart) Total bullets = four (although only one to five bullets are required)  1997 Expanded Problem Focused Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems  Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant Lungs: Clear to auscultation  CV: RRR, no MRGs  Abdomen: Soft, nontender  Extremities: No peripheral edema  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for examination of the abdomen)  (1 bullet for examination of extremities for edema)  Total bullets = six  1997 Detailed Exam  At least two bullets from six organ systems OR 12 bullets from two or more organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Neck: FROM, supple  Lungs: Clear to auscultation  CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or digital cyanosis Skin: no rash, lesions or ulcers  Psych: Alert and oriented to person, place and time  (1 bullet for three vital signs)  (1 bullet for general appearance)  (1 bullet for examination of neck)  (1 bullet for auscultation of lungs)  (1 bullet for auscultation of the heart)  (1 bullet for assessment of carotid arteries)  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  (1 bullet for examination of extremities for edema)  (1 bullet for examination and/or palpation of digits and nails)  (1 bullet for inspection of skin and subcutaneous tissue)  (1 bullet for brief assessment of mental status—orientation) Total bullets = 12  1997 Comprehensive Exam  Two bullets from EACH of nine organ systems Example  Vitals: 120/80, 88, 98.6  General appearance: NAD, conversant  Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA  HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate  Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy  Lungs: CTA, with normal respiratory effort and no intercostal retractions  CV: RRR, no MRGs  Abdomen: Soft, non-tender; no masses or HSM  Extremities: No peripheral edema or extremity lymphadenopathy Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules  Psych: Appropriate affect, alert and oriented to person, place and time  Systems and Bullets  Constitutional  (1 bullet for three vital signs)  (1 bullet for general appearance)  Eyes  (1 bullet for inspection of conjunctivae and lids)  (1 bullet for examination of pupils and irises)  Ears, Nose, Mouth and Throat  (1 bullet for external inspection of ears and nose—“atraumautic”)  (1 bullet for examination of oropharynx)  Neck  (1 bullet for examination of neck)  (1 bullet for examination of the thyroid)  Respiratory  (1 bullet for auscultation of lungs)  (1 bullet for assessment of respiratory effort)  Cardiovascular  (1 bullet for auscultation of heart)  (1 bullet for examination of extremities for edema or varicosities)  Gastrointestinal  (1 bullet for examination of the abdomen)  (1 bullet for examination of liver and spleen)  Lymphatic  (1 bullet for examination of lymph nodes in neck)  (1 bullet for examination of lymph nodes in extremities)  Skin  (1 bullet for inspection of skin and subcutaneous tissues)  (1 bullet for palpation of skin and subcutaneous tissues)  Psychiatric  (1 bullet for description of patient’s judgment and insight)  (1 bullet for brief assessment of mental status—orientation)  Total systems = 10 (although only nine are required)  Total bullets = 20 (although only 18 are required—two in EACH of nine systems)  Organ Systems  The 1997 E/M guidelines recognize the following organ systems:  1. Constitutional  2. Eyes  3. Ears, nose, mouth and throat  4. Neck  5. Respiratory  6. Cardiovascular  7. Chest (breasts)  8. Gastrointestinal (abdomen)  9. Genitourinary (male)  10.Genitourinary (female)  11. Lymphatic  12. Musculoskeletal  13. Skin  14. Neurologic  15. Psychiatric Physical Exam Bullets  Constitutional      1)   Three vital signs     2)    General appearance Eyes      1)   Inspection of conjunctivae and lids      2)   Examination of pupils and irises (PERRLA)      3)   Ophthalmoscopic discs and posterior segments  Ears, Nose, Mouth, and Throat      1)   External appearance of the ears and nose (overall appearance, scars, lesions, masses)      2)   Otoscopic examination of the external auditory canals and tympanic membranes      3)   Assessment of hearing      4)   Inspection of nasal mucosa, septum and turbinates      5)   Inspection of lips, teeth and gums      6)   Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck      1)   Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)      2)   Examination of thyroid  Respiratory      1)   Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)      2)   Percussion of chest (e.g., dullness, flatness, hyperresonance)      3)   Palpation of chest (e.g., tactile fremitus)      4)   Auscultation of the lungs Cardiovascular      1)   Palpation of the heart (location, size, thrills)      2)   Auscultation of the heart with notation of abnormal sounds and murmurs      3)    Assessment of lower extremities for edema and/or varicosities      4)   Examination of the carotid arteries (e.g., pulse amplitude, bruits)      5)   Examination of abdominal aorta (e.g., size, bruits)      6)   Examination of the femoral arteries (e.g., pulse amplitude, bruits)      7)    Examination of the pedal pulses (e.g., pulse amplitude) Chest (Breasts)      1)   Inspection of the breasts (e.g., symmetry, nipple discharge)      2)   Palpation of the breasts and axillae (e.g., masses, lumps, tenderness) Gastrointestinal (Abdomen)      1)   Examination of the abdomen with notation of presence of masses or tenderness      2)   Examination of the liver and spleen      3)   Examination for the presence or absence of hernias      4)   Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,            rectal masses      5)   Obtain stool for occult blood testing when indicated Genitourinary (Male)      1)    Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)      2)   Examination of the penis      1)   Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness) Genitourinary (Female)  Pelvic examination (with or without specimen collection for smears and cultures, which may include:      1)   Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)      2)   Examination of the urethra (e.g., masses, tenderness, scarring)      3)    Examination of the bladder (e.g., fullness, masses, tenderness)      4)   Examination of the cervix (e.g., general appearance, discharge, lesions)      5)   Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)      6)    Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) Lymphatic  Palpation of lymph nodes two or more areas:      1)   Neck      2)    Axillae      3)    Groin      4)   Other Musculoskeletal      1)   Examination of gait and station      2)   Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia,           infections, nodes) Examination of the joints, bones, and muscles of one or more of the following six areas:      a)   head and neck      b)    spine, ribs, and pelvis      c)    right upper extremity      d)   left upper extremity      e)   right lower extremity      f)    left lower extremity The examination of a given area may include:   1)   Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,   2)   defects, tenderness, masses or effusions  3)   Assessment of range of motion with notation of any pain, crepitation or contracture  4)  Assessment of stability with notation of any dislocation, subluxation, or laxity   5)  Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any  atrophy or abnormal movements Skin      1)   Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)     2)   Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic      1)    Test cranial nerves with notation of any deficits      2)   Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)      3)   Examination of sensation (e.g., by touch, pin, vibration, proprioception) Psychiatric      1)   Description of patient’s judgment and insight Brief assessment of mental status which may include     1)   orientation to time, place, and person     2)   recent and remote memory     3)   mood and affect 1997 Specialty Exams can be found here. So there you have it......if you have the time to read through this and understand, you can see that the more you document the better. If you do use an EMR, you probably all ready have this. But if you are on paper, you should update your exam form to include the systems and perhaps even the bullets. This will prompt you to examine "All the pertinent systems" Want to join us? Email us at modifier25@gmail.com

Middle of the Road 99203

According to EM University, in 2003 this code accounted for 39% of all documented office visits in 2003. I wonder why we don't have any further data on this. Wouldn't it be fantastic if we could see who was coding what and how often? Imagine if we could have a website that would present this information to physicians yearly and then match it against your rates? Well, there are some pay services that allow this for subscribers of their service....

I think you know how I feel about someone taking your data, compiling it with others AND THEN SELLING IT BACK TO YOU!

Frankly, that is just bull......I think it should either be outlawed OR we should be given FREE ACCESS to this.

It is after all, OUR DATA.

So with that little rant out. Let me tell you about a 99203

A 99203 is also called a Level 3 New Office Visit. What is it?

This office visit requires 3 key components

1. A Detailed History

2. A Detailed Examination

3. Medical Decision making of LOW complexity

Why do I point out Low complexity? Because, I think we may actually be coding too much of these and may instead need to be coding more 99204s and 99202s....

Let's examine what the definition of "Detailed" is.

"Detailed History"-Requires a Chief Complaint (CC), "extended" HPI, problem pertinent Review of Systems (ROS) which is "extended" tp incude a limited review of:

A. Family History

B. Social History

C. Past Medical History 

All directly related to patient's problem.....

2. Detailed Examination-Requires an "Extended" examination of the affected body area or organ system AND other symptomatic or related organ systems.....

"Extended Examination"- requires 12 data points/bullets.

If you want to learn more about bullets you can see it here.

3. Lastly, Medical Decision Making of "LOW COMPLEXITY"

Which requires

1. Limited number of Diagnoses or Management Options

2. Limited amount of data to review

3. Low complexity of data to review

4. Disease with low morbidity or mortality

So the question remains...."What does this look like?"

Initial offive visit for a 67 year old woman with hypertension, new to the area. She has had no problems with her BP while on a diuretic and home bp monitoring. She brings in her log.

You are expected to do the same things that you would for a 99202

So why do I think we are using this code too much? Here's the question.....would you do such a thorough History or Physical in a patient with well controlled HTN?

Probably not, which would then bump you down to a 99202. 

But what about well controlled diabetes? The mortality and morbidity is higher and you would do more work.....thus a 99204, which I will cover tomorrow......

You see, by choosing middle of the road, we may be coding wrong......

Want to join us? Email us at modifier25@gmail.com You can learn the system and be better at coding too. This may save you 80-100k per year.....

Fridays are Fun Days, Wolfram Alpha Fun!

I will skip writing about coding on Fridays and instead will focus on technology that will bring us closer to removing some of the layers of ineptitude in medicine and the business practice.

Wolfram Alpha is going to change how we understand coding and in fact if done properly, this computational system could put the Athena Health service which I mentioned wanting to charge me 10,000 USD for a set up. If done properly by placing the rejection claims on the internet where Wolfram Alpha could access it. 

Athena Health brags that they have 17,000 US physicians dumping into their database........What if the 700,000 physicians dump this information onto the Internet so that Wolfram Alpha can access it?

It may just so turn out that by writing apps around Wolfram Alpha, we may actually be able to replace the billing software systems as well. 

You see, the CPT code and ICD9/10 system were made for our benefit. Not to cost us money. It will only take a small matter of time before the inevitable has happened.

Wolfram Alpha is soon going to be Wolfram Beta, which will then be Wolfram.....

And we will have just put billions of dollars back in the pockets of doctors.

But it starts with you......joining us and putting this info online.......or at least blogging with us....

Want to join our blog? Email us at modifier25@gmail.com

Is it really a 99202?

Yesterday I mentioned the 99201 CPT E and M code. I said that it turns out most people over code the 99201 as a 99202. But I then thought, how would they know the difference and why would they over code.

Often overcoding is due to ignorance of what is required from each code. And frankly, to quote ex-president Clinton..........It depends on what the definition of Is, Is......

The same is true with words such as problem versus expanded problem.......

What does expanded problem mean? Expanded problem means that you took a problem relevant review of systems......my guess is that most of you do this, but often fail to document this. Review of Systems is super important here. In the 99201 you can get away without doing it in the HPI, but in the 99202 you cannot.

What is the 99202? A new patient which requires 3 components

1. An expanded problem focused history (Includes ROS)

2. An expanded problem focused exam

3. Straightforward medical decision making

So you may be asking yourself, "What is an expanded problem focused exam?"

A limited examination of the affected body area OR organ system affected AND other symptomatic or related organ systems

And now I hope you understand Straightforward Medical Decision Making......If not...

It is determined by:

1. The number of possible diagnoses if greater than 3 is usually complex....make sure you list differentials in your notes!!!

2. The amount of or complexity of medical records. labs, and other information that must be reviewed. Document ALL records reviewed in your notes.....

3. The risk of complications, morbidity and mortality associated with the problems, procedures and management options....

I hope you now see why cardiologists/surgeons/gastroenterologists get paid so much more than internists......EVERY SINGLE ONE OF THEIR CASES can be billed at higher levels of medical decision making.....

So, with that primer, let's see a 99202 in action.....

A 45 year old man is in with history and skin findings consistent with poison oak who is not responding to OTC treatment....

What is expected of you:

1. Preservice, review the medical history forms AND vital signs

2. Intraservice, Obtain the expanded problem history and physical, Formulate a diagnosis, formulate a treatment plan-Straight forward here-i.e. less than 3 differentials and simple treatment either way....Don't try and fudge this one...it is what it is....now reconcile your meds, write the Rx and test if you really need to...

3.  Document what you did, including listing dif Dx, care coordinate AND handle another treatment failure prn....

There, that wasn't so tough......Now how many of these do you see in a day....my guess is a whole lot more than you had thought about if you are new......if you are established, probably one to 2 a day at maximum.....

Want to Join us? Email me at modifier25@gmail.com so you can start blogging and learning codes too!

Welcome to my first Initiates!

I just received 3 emails from doctors looking to join the fray. They came from MedScape!

Welcome. Today I wanted to go over some simple things first. The Current Procedural Terminology Evaluation and Management Codes. These codes were introduced into the system in 1992 so they are only 17 years old. Yes that is correct, 17 years of insanity. Which is why the whole field has only gotten even more bloated lately.....

Prior to the E and M codes "visit" codes were used. Which obviously made a lot more sense to physicians who usually had their day scheduled as such with types of visits as comprehensive physicals and brief check ups.....

But, to dismantle the system we need to do it systematically. That is, by finding out what these codes mean and then applying them appropriately.

The next 5 days will be spent on the new patient E and M codes.

We start off the 9920x series with 99201. Office or outpatient visit for the new patient.

99201 requires 3 things.

1. A focused Problem History

2. A problem focused exam

3. Straight forward Medical Decision Making (This is the little bastard that gets us all)

As physicians, I think we need a good understanding and the best way to do that is with a clinical example of a 99201.....so here you go.

Initial visit for a 24 year old here for a refill of her acne cream.

These insurers are assuming you are doing the following things for this patient and it would be wise to document these as well as the mandatories.

1. Preservice-review the medical history form that the patient filled out while in the waiting room

2. Intraservice-Problem focused exam-in this case the skin, Formulate a treatment plan, discuss this with the patient. Also, discuss the need for preventative health maint....Reconcile medications and write an Rx as needed

3. Postservice-Complete the medical documentation, handle treatment failure if that happens, provide care coordination......

Pretty simple huh? How many people bill this one as a 99202???? I bet a ton of you do. But you will soon see that the cost of an audit is more than the extra few bucks you might get for jumping from a 1 to a 2.....

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